UAMS Oral Health Clinic Patient Registration Form
Date of birth
___________________ Referred by
______________ Zip Code___________________________
Responsible Party Information:
Spouse’s/Parent’s Name (circle one) I
Date of birth
______________________ □ Responsible party is policy holder for patient
Nearest relative not living with you
____________________________________ Phone Number
Primary Dental Insurance Company
_________________________________________________ Phone Number
___________________________ Date of birth
_________________ Group #
___________________________________________ ID #
Secondary Dental Insurance Company
___________________________ Date of birth
_________________ Group #
___________________________________________ ID #
PATIENT NAME _______________________________________________ Birth Date _____________________________________
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may
have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any
other medications containing bisphosphonates?
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
Have you ever had any serious illness not listed above?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________
University of Arkansas for Medical Sciences Oral Health Clinic
Clinical Policies and Patient Rights
The UAMS Oral Health Clinic is part of the College of Health Profession’s Center for Dental Education. The OHC is a
General Dentistry Practice designed to provide clinical education and experience to student and residency programs. Because teaching and education is a primary responsibility of this clinic, our operations differ somewhat from the typical private dental practice. Please take the opportunity to review this “Clinical Policies and Patient Rights” statement. You will be asked to sign a separate consent form indicating your willingness to proceed. We are grateful that you have chosen UAMS for your dental needs, and we appreciate your patience and cooperation with the uniform application of these policies.
The UAMS Oral Health Clinic welcomes all new patients. The OHC does not discriminate on the basis of age, sex, race, or
handicapping condition. Should you require special care due to a hardship, please inform our staff. In the interest of providing
comprehensive care to our patients, the OHC will provide all new patients over the age of 18 years with an initial appointment for
a comprehensive evaluation to include medical history review, extra/intra-oral examination, appropriate radiograph(s) as
determined by the individual’s needs, individualized patient education including oral hygiene instructions, and diagnosis. After
the comprehensive evaluation, you will be informed on your oral health status and your subsequent treatment needs. All treatment
will be rendered under the supervising dentist and will meet the highest standards recognized by the dental and dental hygiene
profession. We ask that you arrive 20 minutes prior to the start of your first dental appointment to allow completion of patient
registration and medical history forms. Please bring your driver’s license or another form of photo ID along with your dental
Children and Minors Under 18
All minors must have the medical history and consent for treatment signed by a parent or guardian prior to treatment. No children are allowed in the clinic operatories areas unless being treated as a patient. Our clinic is not equipped to provide child care or
babysitting services. Please make arrangements to have your children properly supervised when you are receiving treatment.
X-rays (dental radiographs) are a necessary part of your diagnosis and treatment. Current radiographs are required of all patients. The type of radiographs prescribed by the dentist will be based upon your individual needs. Refusal to have radiographs taken or to pro
vide current radiographs from your previous dentist’s office may prevent us from accurately assessing your dental condition
and could result in the inability to render certain dental treatments. Previous radiographs can be mailed to us or transferred to us electro
nically by your previous dentist once you provide consent to release information. If these images are not of diagnostic
quality, a repeat may be needed. You are responsible for arranging the dental record transfer prior to your first scheduled appoint ment in the OHC. Upon your request, an electronic duplicate of any pertinent radiographs on file with the OHC will be sent to a private dentist or other institution for a $15.00 duplication fee.
For your protection, all dental instruments are sterilized and dental units are disinfected after each patient. Students, residents,
and faculty are required to wear masks, gloves, and glasses during patient treatment. The OHC maintains the infection control
guidelines set forth by the Centers for Disease Control and Prevention (CDCP) and the Occupational Safety and Health
We request your cooperation in appearing on time for your scheduled appointments. Depending on the individual needs, several appointments may be necessary to complete treatment. If you are unable to keep your previously arranged appointment time,
please provide 24 hours’ notice to our receptionist. If you do not appear for a previously arranged appointment it will be considered a broken appointment.
Three broken appointments will result in your dismissal as a patient in the clinic.
Patients are to park in the UAMS Patient and Visitor parking decks.
Payment of services is due at the time treatment is provided. Payment must be made in full by cash, check, or credit card.
UAMS financial policy does not allow for payment plans or extension of credit. You will be given a receipt for services and fees
at the conclusion of each dental visit. If you have dental insurance, you will be given an estimated
cost for the treatment rendered.
You are financially responsible for any and all remaining fees that your insurance plan does not cover.
The OHC will file dental insurance claims as a courtesy to our patients. We will attempt to answer any questions relating to your dental insurance plan when you contact us; however, understand that you are the financially responsible party for any charges
not covered by your insurance. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what
your insurance will or will not do with each claim. To meet our contractual agreements with certain dental plans, you will be asked below to assign your benefits to the OHC which will permit us to only collect deductibles and co-payments at the time of
service. Please remember to promptly notify the clinic to update your insurance records whenever plan coverage changes.
Students are not allowed to use cellular devices in order to focus on your treatment. Therefore, we ask that you return the same
courtesy to our students and the supervising faculty by refraining from making or receiving phone calls or text messages while in
the treatment areas. Each cell phone should be turned OFF
or placed on MUTE
while receiving dental treatment.
Photography and Video
Photography and video is frequently employed to assist in the
diagnosis of certain dental conditions. The gathering of diagnostic
images is considered a part of your general consent for treatment. However, certain clinical situations may present the
opportunity to document procedures for purposes of education, including publications in professional journals or books. A separate authorization to take and release patient photographs and video/audio recordings will be presented for your signature in
the event that teaching materials are being gathered. If you sign this special consent form, all photographs, recordings, video, or
drawings will remain the sole property of the UAMS Oral Health Clinic and may be used by members of the faculty or released
Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the
dentistry you will receive. To ensure that appropriate precautions are taken according to each person’s physical status as
determined by medical history, physician’s recommendations, and/or risk factors, each patient must have a completed medical history form. It is the responsibility of the patient to provide accurate and up-to-date information at each dental appointment,
including a complete medication list with current dosing. Dental procedures will not be initiated until there are no unresolved questions remaining in the medical history. Inadequate or inaccurate information can be dangerous to your health.
General Consent for Treatment
By signing the UAMS “General Consent for Treatment” form, you are making formal application to the University of Arkansas for Medical Sciences Oral Health Clinic for admission to their patient health care system. Your signature also acknowledges that you have received a copy of the UAMS “Notice of Privacy Practices” and this “Clinic Policies and Patient Rights” statement. Your signature will give us general permission to complete various indicated dental treatments (including local, oral, and inhalation anesthetics along with surgical dental procedures). For such treatment, you agree to pay the charges set by the clinic independent of any dental insurance benefits. You also agree to be treated by dental residents or students under the direct supervision of our licensed dentists and hygienists according to Arkansas state law. Your signed consent acknowledges that all diagnostic aids, including radiographs and/or photographs are the property of the UAMS Oral Health Clinic. By signing, you will retain the right to refuse any or all treatment but this may result in referral for treatment elsewhere. Your signed consent states that it is your responsibility to make and keep all scheduled appointments for yourself and your children or trustees and to complete all planned treatment in a timely manner. You will also sign to give consent for the initial care and all subsequent care for your children or trustees unless affirmatively revoked in writing. The General Consent for Treatment form also has a section for signature which indicates that you consent to accept “assignment of dental benefits” if insured.
NOTICE OF PRIVACY PRACTICES
Effective Date: May 1, 2009
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice is provided on behalf of the University of Arkansas for Medical Sciences including its Medical Center and clinics, Psychiatric
Research Institute, Area Health Education Centers, and other facilities (“UAMS”). UAMS provides patient care through a healthcare
system committed to education and research.
This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information to carry out treatment,
payment or healthcare operations and for other purposes permitted or required by law. “Protected Health Information” is information that may
identify the patient and that relates to the patient’s past, present or future physical or mental health, and may include name, address, phone numbers
and other identifying information.
We are required to give you this Notice and to maintain the privacy of your Protected Health Information. We must abide by this Notice, but we
reserve the right to change the privacy practices described in it. A current version of this Notice, with required revisions, if any, may be obtained
from the UAMS web site,and will be posted in prominent areas of our facilities. You may also receive a current copy by sending
a written request to the UAMS HIPAA Office, 4301 W. Markham #829, Little Rock, AR 72205.
We understand that medical information about you and your health is personal and confidential, and we are committed to protecting the
confidentiality of your medical information. We create a record of the care and services you receive at UAMS Medical Center and its clinics, Area
Health Education Centers and other UAMS facilities. We need this record to provide services to you and to comply with certain legal
requirements. This Notice will tell you about the ways we may use and disclose your information. We also describe your rights and certain
obligations we have to use and disclose your health information.
If you believe your Privacy Rights have been violated, you may complain to us or to the U.S. Secretary of Health and Human Services. To file a
complaint with us, you may send a letter describing the violation to the UAMS HIPAA Officer, 4301 W. Markham #829, Little Rock, AR 72205.
There will be no retaliation for filing a complaint.
If you have questions or need more information, contact the UAMS HIPAA Officer at 501-614-2187. WHO WILL FOLLOW THIS NOTICE:
This Notice describes the practices of UAMS healthcare professionals, employees, volunteers and
others who work or provide healthcare services at any UAMS facility, including students-in-training. ACKNOWLEDGMENT:
You will be asked to sign an Acknowledgment of receipt of this Notice. The delivery of your healthcare services will
in no way be conditioned upon the signing of this Acknowledgment.
Your Privacy Rights.
You have the following rights relating to your Protected Health Information and may:
Obtain a current paper copy of this Notice.
Inspect or obtain a copy of your records. Your request to obtain a copy of your medical records must be in writing. You may be charged a fee for the cost of copying, mailing or other supplies. We are allowed to deny this request under certain circumstances. In some situations, you have the right to have the denial of your request reviewed by a licensed healthcare professional identified by UAMS who was not involved in the original denial decision. We will comply with the outcome of this review.
Request that we amend your record, if you feel the information is incomplete or incorrect. We are allowed to deny this request in certain circumstances and may ask you to put these requests in writing and provide a reason that supports your request.
Request in writing a restriction on certain uses and disclosures of your information. We are not required to agree to the requested restrictions in all circumstances.
Obtain a record of certain disclosures of your Protected Health Information.
Make a reasonable request to have confidential communications of your Protected Health Information sent to you by alternative means or at alternative locations.
We will obtain your written permission for uses and disclosures of your Protected Health Information that are not covered by the Notice or permitted by law. Except to the extent that the use or disclosure has already occurred, you may cancel this permission. This request to cancel must be put in writing.
Submit any written requests to inspect, copy or amend your records to the Medical Records Department.
We are required to protect the privacy of your Protected Health Information, abide by the terms of the Notice, and make the
Notice available to you.
Examples of Uses & Disclosures
We will use your Protected Health Information for treatment. Certain information obtained by a nurse, doctor, therapist, or other healthcare worker
will be put into your record and used to plan and manage your treatment. We may provide reports or other information to your doctor or other
authorized persons who are involved in your care.
We will use your Protected Health Information for payment. A bill will be sent to you and/or your insurance company with information about your
diagnosis, procedures and supplies used.
We will use your Protected Health Information for regular healthcare operations. The Medical Staff and other healthcare workers may use your
Protected Health Information to check on the care you received, how you responded to it, and for other business purposes related to operating the
hospital or clinics.
Business Associates: We may share some of your Protected Health Information with outside people or companies who provide services for us,
such as typing physician reports.
Patient Directory: Unless you tell us not to, we may use and disclose your name, location in the facility, and general condition to people who ask
for you by name. If provided by you, your religious affiliation will only be given to members of the clergy. If you are a patient at the Psychiatric
Research Institute (PRI), you will not be part of the Patient Directory while you are at the PRI, and we will not provide directory information to
people who ask for you by name, unless you specifically tell us to.
Notification: We may use or disclose your Protected Health Information to notify a family member or other person involved in your care, your
location and general condition unless you tell us not to do so.
Communication with family: We may share your Protected Health Information with a family member, a close personal friend, or a person that you
identify, if we determine they are involved in your care or in payment for your care, unless you tell us not to do so.
Research: Your Protected Health Information may be used for research purposes in certain circumstances with your permission, or after we
receive approval from a special review board whose members review and approve the research project.
Coroners, Medical Examiners, Funeral Directors: We may disclose your Protected Health Information to these people, to the extent allowed by
law, so that they may carry out their duties.
Organ Donor Organizations: We may share your Protected Health Information with the organ donation agency for the purpose of tissue or organ
donation in certain circumstances and as required by law.
Contacts: We may contact you to provide appointment reminders or to tell you about new treatments or services.
Fundraising and Marketing: We may contact you as part of any fundraising or marketing efforts.
Food and Drug Administration (FDA): We may share your Protected Health Information with certain government agencies like the FDA so they
can recall drugs or equipment.
Workers Compensation: We may disclose your Protected Health Information for workers' compensation claims.
Public Health: We may give your Protected Health Information to public health agencies who are charged with preventing or controlling disease,
injury or disability and as required by law.
Communicable Disease: We may disclose your Protected Health Information to a person who may have been exposed to a communicable disease
or may otherwise be at risk of contracting or spreading the disease or condition, if authorized by law to do so, such as a disease requiring isolation.
Correctional Institution: If you are an inmate of a correctional institution, we may disclose your Protected Health Information needed for your
health or the health and safety of others.
Law Enforcement: We must disclose your Protected Health Information for law enforcement purposes as required by law.
As Required by Law: We must disclose your Protected Health Information when required by federal, state or local law.
Health Oversight: We must disclose your Protected Health Information to a health oversight agency for activities authorized by law, such as
investigations and inspections. Oversight agencies are those that oversee the healthcare system, government benefit programs, such as Medicaid,
and other government regulatory programs.
Abuse or Neglect: We must disclose your Protected Health Information to government authorities that are authorized by law to receive reports of
suspected abuse or neglect.
Legal Proceedings: We may disclose your Protected Health Information in the course of any judicial or administrative proceeding or in response to
a court order, subpoena, discovery request or other lawful process.
Required Uses and Disclosures: We must make disclosures when required by the Secretary of the Department of Health and Human Services to
investigate or determine our compliance with the HIPAA Privacy Regulations.
To Avoid Harm: We may use and disclose information about you when necessary to prevent a serious threat to your health or safety or the health
or safety of the public or another person.
For Specific Government Functions: In certain situations, we may disclose Protected Health Information of military personnel and veterans. We
may disclose your Protected Health Information for national security activities required by law.
University of Arkansas for Medical Sciences Oral Health Clinic
General Consent for Treatment and Assignment of Dental Insurance Benefits for:
Legal Name (Print) ________________________________________________
For the purpose of full disclosure, you have been given copies of the UAMS “Notice of Privacy
Practices” form and the UAMS Oral Health Clinic “Clinical Policies and Patient Rights” form. By
signing and dating below, you are providing certain consents to proceed which allow us to provide
actions on your behalf or in behalf of others you may represent. We are grateful that you have chosen
UAMS for your dental needs, and we appreciate your patience and cooperation with the uniform
application of UAMS policies. I. General Consent for Treatment, Receipt of Policy Statements, and Release of Information
A. I hereby apply to the University of Arkansas for Medical Sciences Oral Health Clinic for admission, and give
permission to complete various indicated dental treatments (including local, oral, and inhalation anesthetics with surgical dental procedures). I have carefully and accurately completed a written medical history and agree to update my medical information at each clinic visit. It is understood that the UAMS Oral Health Clinic is for instruction of and demonstration to the residents and students. I hereby agree that I may be treated by dental residents or students under the direct supervision of licensed dentists and hygienists according to state law. I understand that all diagnostic aids, including radiographs and/or photographs are the property of the UAMS Oral Health Clinic. I have the right to refuse any or all treatment at which time I may be referred for treatment elsewhere. Upon acceptance of the recommended treatment, it is my responsibility to make and keep all scheduled appointments and to complete the planned treatment in a timely manner.
B. I have received a copy of the UAMS “Notice of Privacy Practices” form and the UAMS Oral Health Clinic “Clinical
Policies and Patient Rights” form. My signature below confirms that I agree to abide by all stated policies.
C. I authorize the UAMS Oral Health Clinic to release any and all medical/dental information to my insurance
company(s) or other physicians or hospitals involved in my treatment or for treatment of my children or trustees.
Signature ____________________________________________________Date _________________________________
II. Consent for Children and Minors Under 18
I hereby give my consent for initial care and all subsequent care to the Oral Health Clinic faculty, residents, and students to provide any and all necessary dental services for my child unless affirmatively revoked in writing.
Child/Minor’s name______________________________________ Relationship to patient _______________________
Signature ___________________________________________________ Date _________________________________
III. Assignment of Dental Insurance Benefits
When applicable, my signature below indicates that I consent to allow the Oral Health Clinic to accept “assignment of benefits” for my/my beneficiaries dental insurance plan and authorize all plan payments be made directly to the OHC.
Signature ____________________________________________________ Date ________________________________
State relationship if other than patient
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